Provider Demographics
NPI:1114290269
Name:TOLLIVER, STACY RAE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:RAE
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 GREENBRIER DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4517
Mailing Address - Country:US
Mailing Address - Phone:208-949-0004
Mailing Address - Fax:
Practice Address - Street 1:3712 GREENBRIER DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-4517
Practice Address - Country:US
Practice Address - Phone:208-949-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 10011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical